In and out of hospital

Copyright © 2018

Any part of this publication may be cited, translated into other languages or adapted to meet the local needs without prior permission of the British Red Cross, provided that the source is clearly stated.

Photo credits: Cover photo © Simon Rawles, page 4 © Simon Rawles, page 8 © Nick Strugnell, page 10 © Simon Rawles, page 14 © Patrick Harrison/British Red Cross.

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For more information on the policy recommendations and research, please contact advocacy@redcross.org.uk

Foreword 5

No more missed opportunities: our recommendations 6-7

Our research 8

Issues faced by the people we support 9-10

Mind the gap: views of health and social care professionals and Red Cross volunteers and staff 11-14

How the British Red Cross helps people home from hospital in 10 simple steps 15

Contents

4 In and out of hospital

5In and out of hospital

The British Red Cross plays a unique role in health and social care in the UK. Our staff and volunteers are working with emergency departments across

the country, providing ambulance support, transporting patients to and from hospital and supporting tens of thousands of older and vulnerable people in their homes. This gives us unique insight into every stage of a patient’s journey, from home to hospital and back again.

Our privileged position allows us to bear witness to the fantastic amount of good work within the health and social care system. But we also see the stresses, many of them preventable, that these services are under. Crucially, we also see where people are falling through the gaps.

This report is the culmination of a programme of research that we have undertaken, which paints a bleak picture of the stress the system is under. All too often, we see vulnerable people having to reach a crisis point before they receive support. Others are caught in an endless cycle of avoidable hospital readmissions, with too many missed opportunities to rectify this.

Latest figures show that emergency hospital readmissions have risen by 22.8 per cent in the last five years.1 Worryingly, the number of people being readmitted to hospital within 48 hours now accounts for one in five of all emergency readmissions.2

Today we see too many missed opportunities to prevent a person’s health from deteriorating or to stop their problems from reoccurring

1 This compares to a 9.3 per cent rise in overall admissions to hospitals during the same period. Healthwatch (October 2017).2 Healthwatch (October 2017).3 National Audit Office, Discharging older patients from hospital, (May 2016).

once they are discharged. Hospitals are not always noticing when somebody comes in and out multiple times. Simple measures such as establishing somebody’s mobility needs before they return home are routinely missed. Nor are homes assessed for falls hazards, which may lead to a person returning to hospital far too soon. Some of our service users even told us they feel unsafe in their own homes.

People are getting stuck in hospital, often because of a lack of care closer to home – particularly those living on their own. The impact this has on people and the system is hard to overstate. Older people are estimated to lose up to five per cent of muscle strength per day in hospital, ultimately reducing their ability to live independently at home once discharged.3

It is also vital that the health system gets better at admitting people only when it’s medically necessary and is equipped to do so safely. Appropriate safeguards must also be in place before vulnerable people are discharged.

Our research has broadened our understanding of these issues from the perspective of people at the forefront of our system: whether that be the person receiving care or the doctor or nurse providing it. While a lack of resources underpins most of the issues set out in the report, we have tried to identify some relatively simple steps that we believe could improve patient flow. We hope these measures will go a long way towards ensuring that more people go on to live healthy and fulfilling lives.

Foreword

6 In and out of hospital

No more missed opportunities: our recommendations

We know that many hospitals are under serious pressure this winter and that, for many areas, these pressures will continue all year round. The need for more resources, not least for adult social care and interventions to prevent people reaching a crisis point, underpins most of the issues explored above.

Nonetheless, there are a number of practical, simple solutions that could make a big difference both to people and ‘patient flow’,4 at minimal cost to the health service.

The research we have conducted, including insights from our own front line staff and service users, has informed our recommendations. The key findings are laid out below.

Helping people feel safe at home> Automatic home assessments should

be triggered for people who have come in and out of hospital several times within a few months. We encounter people who have come in and out of hospital with nobody questioning why their needs have spiralled into something much more complex. While people might appear to be medically fit enough for discharge, a regular cycle of readmission often signals that something is amiss at home.

> The Government should seed-fund proactive falls prevention schemes, ensuring people can access the simple home adaptations and mobility aids they need to live independently at home.

> People who live alone, have poor mobility and have been in and out of hospital due to falls should automatically have their home assessed for falls hazards before they are discharged.

4 The movement of patients along a pathway of care, including in, through and out of hospitals.

Avoiding unnecessary hospital admission> Invest in non-clinical personnel in

A&Es to help prevent people who are medically OK but need support at home from being admitted. Non-clinical personnel have the time to provide the flexible, person-centred support others in busy accident and emergency departments often do not have time for. Importantly, they are able to take people home safely who might need a little bit of support but do not need to be in hospital.

> Ensure there are more multidisciplinary teams who work with people at risk of being admitted into hospital. These teams should be located in the same offices, have regular meetings and shared access to care records. Voluntary and community sector representatives should be fully involved in these teams.

Helping people home from hospital > All discharge ‘checklists’ must include

an assessment of equipment and medication needs, from wheelchairs to blister packs. These should be arranged before leaving hospital.

> At a minimum, transport home from hospital should be offered to all those who live alone, who are leaving hospital alone and have poor mobility. Anybody transported home should be assisted inside. Assisting patients inside their home provides an opportunity to check their home environment.

7In and out of hospital

> Frail patients whose transfer back to the community has been delayed should be encouraged and assisted to get dressed and walk around every day they are in hospital so that their condition does not deteriorate.5

Between home and hospital with the British Red CrossThe British Red Cross has been working between home and hospital since before the NHS was established. Today our health and social care services help over 200,000 people across the country continue to live safely and independently.

Across the UK, we help:

> 80,000 people to live independently at home

• 30,000 people through our A&E discharge support

• 50,000 people get Home from Hospital

> 125,000 through a combination of support including transport to and from hospital

> 90,000 people with short-term access to mobility aids such as wheelchairs.

Our services have a simple idea at their heart: preventing health problems from escalating into personal crises. At their best, they enable people to regain their confidence and independence.

It is this position, working within both the community and hospitals, which gives us a unique insight into where people are falling through the gaps.

Much of our operational work is focused on getting people home safely from both A&Es and hospital wards. We work in hospitals across the country, providing the practical and emotional support others might not have time for. We might sit with disorientated patients,

5 Older people are estimated to lose 5 per cent of muscle strength per day in hospital, ultimately reducing their ability to live independently at home once discharged. National Audit Office Discharging older patients from hospital (May 2016).

collect prescriptions and take people home who need a little bit of support but do not need to be in hospital.

Outside hospitals, we carry out home assessments. We check simple things like whether there are falls hazards, whether the heating is on, if there's food in the fridge, whether the person has existing support networks or mobility needs and much more. We might help somebody for a few days or a few months.

“ We try and get in [to the home] as soon as we can because we don’t know what we’re going to find when we get there.” Red Cross volunteer

Sometimes our services help people avoid hospital in the first place. We work in multidisciplinary teams in some parts of the country, helping people with complex needs avoid hospital. Some of our services have been focussed on helping people who frequently attend hospital to seek the help they need to live safely in their communities. One partnership with a mental health trust, for example, has successfully reduced pressures on the system while helping people, some of whom had lost all hope, go on to live fulfilling lives.

Indeed, so much of our work is about spending time building relationships with the people using our services. We might learn, for example, that somebody won’t leave their house because they are afraid of falling. In this case, something as simple as a ramp could make all the difference. Sometimes it’s a wheelchair, or help managing finances so that the heating is not cut off.

Again and again we find that by taking the time to get to know people, we learn just how big small interventions can be. So often, they prove the difference between living independently at home and being admitted to a care home or hospital.

8 In and out of hospital

We have gathered the insights and experiences of a range of people working within hospitals, in people’s homes and the space between – from nurses to our own independent living volunteers – as well as Red Cross service users themselves.

Over the second half of 2017 we:

> Carried out six focus groups across England with around 50 of our independent living staff and volunteers, exploring the problems and solutions in the health and social care system.

> Commissioned five focus groups with health and social care professionals from across England, including: GPs, A&E nurses, social workers, occupational therapists, community nurses, discharge planning team members, paramedics, falls prevention team members and physiotherapists.

> Commissioned a survey of just under 100 people using our independent living services and 10 in-depth interviews, which has given us further insight into everyday needs and experiences. This builds on a larger study The Crises Facing Our Independent Living Service Users, that we published in 2016.6

This research combines to paint a bleak picture of the strain hospitals and social care services are under. We are seeing more and more people discharged without adequate attention being given to their home environment, while others are deteriorating in hospital while they wait for a care package to be put in place.

6 The 2017 survey and in-depth interviews were carried out byFACTS International and the external focus groups were carried outby Community Research. The 2016 research, The Crises FacingOur Independent Living Service Users, was based on a survey of 170service users, 29 in-depth interviews with service users and 22 expertinterviews with staff.

Our research

9In and out of hospital

“ It is to do with my walking ability, I can stagger, I am not steady.” Female, 35-49

“ She has to get out of the chair, into her wheelchair, to get to the commode the other side of the room, and that is quite a struggle, in fact, she’s had a number of falls this week.” Male, 75-84

Our survey of just under 100 of our independent living service users provides a unique insight into the lives of those who rely on our health and social care system.

The participants were a range of ages and used a range of Red Cross services, from A&E assisted discharge and transport, to our home from hospital and support at home services.

Over 90 per cent of those surveyed were limited by a health problem or disability expected to last at least 12 months. The majority were limited by a mobility issue or by stamina or breathing difficulty. They also often had more than one long-term issue and 38 per cent had three or more conditions.

Feeling unsafeOver half the people we spoke to did not feel completely safe in their own home. People who are ‘limited a lot’ by a long-term health disability were, perhaps unsurprisingly, more likely to say they feel less safe in and outside their home.

The most common reason people felt unsafe was around falling outside the home (68 per cent) and inside the home (57 per cent). These fears are not unfounded: 30 per cent of people aged over 65 will fall at least once a year; this

7 Public Health England.8 Public Health England Falls and fracture consensus statement Supporting commissioning for prevention (January 2017).

increases to 50 per cent for those aged over 80.7 All too often an avoidable fall can be the start of a downwards spiral.

“ If I want to post a letter at the end of the street, I would just love to be able to just do it. My balance has been poor since I had my falls and I now I need an arm to balance.” Female, over 85

The overriding impression given by this research is just how scary everyday activities can be to people who struggle with their mobility. People are effectively afraid of their own front door, the shower, going to the post office, changing the lightbulbs, the staircase, and so on.

“ I’ve got a shower over the bath. That is a little bit of a difficulty, even now. I have to sort of get my legs cocked over the bath, to get even into the bath to get my shower.” Female, 75-84

We believe that that there are usually relatively simple solutions to these well-founded fears: the provision of mobility aids, exercise classes to build up strength, checking for falls hazards at home. It’s estimated that addressing falls hazards in the home could save the NHS in England £435m a year.8

Struggling with everyday tasksOn average, our service users reported having difficulty with seven out of 15 everyday tasks: ranging from doing work around the house, getting dressed, managing finances and washing to preparing a hot meal.

Issues faced by the people we support

10 In and out of hospital

The top three activities most struggled with are: doing work around their house or garden (87 per cent), walking 100 yards (71 per cent) and climbing one flight of stairs without resting (70 per cent).

Our 2016 study of 170 Red Cross service users found that many struggled to take out the rubbish. Indeed, what was perceived as hoarding was often down to poor mobility – not being able to tidy up, move things around or pick things up. Living in an untidy environment can lead to somebody’s condition worsening, as well as heightening somebody’s risk of falling.

Almost 60 per cent struggled with bathing or showering, a third with walking across the room and getting in and out of bed and 23 per cent struggled with taking their medicine.

Living alone Many of our service users live alone – almost 70 per cent of those surveyed. Despite struggling with everyday tasks such as bathing and dressing themselves, we found that those living alone were less likely to access both informal support from family and friends and formal support from local authorities and charities. Just 47 per cent received regular help from a friend or loved one, compared to 90 per cent of people living with others. Similarly, only 30 per cent of those living alone were receiving help from the local authority with personal care compared to 47 per cent of those living with others.

With older people increasingly living alone, we believe that targeting support at those living without support networks is vital to prevent a continuous cycle of preventable hospital admissions.

Struggling but caring for others

A significant minority were caring for someone else while contending with their own conditions.

“ I would like to go out more but my partner is also disabled, we look after each other and have to be together twenty-four seven.” Anonymous

What they would like to do but can’tMany of our service users told us that there are many things they would like to do but cannot – which, in turn, affects their sense of freedom and confidence.

“ To be able to get up in the morning and get washed or showered and dressed and then the same at night, but without planning. I worry about undoing all the good work that has been done on my hip, if I were to fall.” Female, 75-84

“ I would like to be able to transfer myself from the wheelchair on to the sofa. I can’t do that at the moment.” Anonymous

11In and out of hospital

Delayed discharge“ A patient medically fit for discharge stayed in

the hospital for two weeks waiting for a social care package. That happened so many times when I was working in the wards… They would then pick up other problems. Then they would not be medically fit. Then they would go to the back of the queue for the social care because they’re not ready to go – get out of hospital – then they’d be waiting another few weeks for another package of care and exactly the same thing would happen.” Social Worker, Birmingham

While over half of delays in discharge in October 2017 were attributable to the NHS, with many waiting for ‘non-acute NHS care’9, we know that the lack of available adult social care is a growing major factor in delaying hospital discharge. In fact, delayed transfers from hospitals due to social care have risen by 65 per cent since 2011.10 Over a third of delayed transfers are attributable to social care: the main reason for social care delays in October 2017 was “Patients Awaiting Care Package in their Own Home”.

For older patients in particular, each day in hospital risks reducing their mobility. Some studies have found a reduction in muscle strength of as much as 5 per cent per day.11

Health and social care practitioners raised the issue of reduced community and intermediate care services, a corollary of which is patients staying in hospital longer than they medically need to.

9 NHS England, Statistical Press Notice Monthly Delayed Transfers of Care Data, England (October 2017). 10 House of Commons Library briefing paper, NHS Indicators; England, (February 2017). 11 National Audit Office, Discharging older patients from hospital, (May 2016).

“ The pots of money for the packages of care and all that's been whittled down. If that's gone and your nursing home bed's gone, well that's just going to create crisis in other areas. It's hospitals that are feeling it because we can't get the patients out, because there's nowhere to get them out to.”

Occupational therapist, Manchester

Inappropriate discharge“ Sometimes like this 84 year old and they'll

go, 'Right, they're medically fit,' and I'd go, 'Actually they need their package of care restarting, which might take 24/48 hours.' I know the hospital is not always the best environment for people, but for some people just an extra 24/48 hours is enough for them to go home, be fine, and actually have not come back in. Sometimes even just holding them on for 24 hours makes a huge difference, even when you're chocka.” Occupational therapist, Manchester

The Red Cross volunteers and staff, and the health care professionals we spoke to, expressed concern not only about delayed transfers of care and the impact on people, but also about inappropriate discharge. They point to a number of cases where patients have been sent home from hospital before adequate support is available or arranged.

“ They've got no family, they've got no one and there's no care package in place for them coming home. They [the discharge team] just ask us to go in, and we go in and we find them, they've either had a fall, they're on the floor and it's because they've been sent back out too soon and they get readmitted again.” Red Cross team member

Mind the gap: views of health and social care professionals and Red Cross volunteers and staff

12 In and out of hospital

Time and again they are seeing inadequate consideration given to what will greet a patient when they get home as a result of the pressure to free up beds.

“They let her home, she didn't have any food. She'd been in there for two months, so all the food in the fridge had all gone mouldy, there was no food there. She'd got home, nobody to help her.” Red Cross team member

Red Cross volunteers and staff also spoke about people being transported home from hospital, only to be left in their car park, unable to make their way inside.

“ He’d actually been sent home eleven o’clock at night. The ambulance had dropped him in his car park on his crutches, and driven away.” Red Cross team member

Assisting patients inside their home provides an opportunity to check their home environment. Checking their home is safe would likely help reduce the number of emergency readmissions within 48 hours of discharge, reported to make up more than one in five readmissions.12

Others pointed out that pressure to free up beds could sometimes result in qualified nursing or occupational therapists being diverted away from their substantive roles to do discharge planning.

Sometimes care packages have been organised, but due to pressures in social care, they are not adequately implemented:

“ A lot of the time, the care agencies are so stretched that they can't actually meet the needs that are required on the actual referral, so the ward might say she needs – or the social worker might say she needs four times a day carers, but actually the care agencies can't provide it, so carers don't show up, or they might need a double visit but only one carer can go – it's constantly happening, constantly happening. ” Falls prevention team nurse, London

12 Healthwatch, What do the numbers say about emergency readmissions to hospital? (October 2017).

In-home assessments“ Often it's about getting them well enough to

be able to go home but actually in the home is often what’s causing the decline in health because of the way that they are living and the lack of support at home. So if [only] you could see what they’re like at home and assess them.” Community nurse, Bradford

In-home assessments were frequently mentioned by the Red Cross staff and volunteers as well as health and social care professionals we spoke to as being crucial to ending a continuous cycle of hospital readmissions.

“ And people we see have just come into hospital because they've had a fall and broken their hip, and then we turn up after they've been discharged… there's no gas, there's no electric, they're living in a messy house; they've not really been coping getting their food, they've just been getting by. ” Red Cross volunteer

All too often, the professionals and Red Cross volunteers and staff we spoke to saw scenarios where older or vulnerable patients were sent home without the right care in place, only to return to emergency departments.

“ When she went into hospital, they kept sending her home the same day, but she was still living in the same squalor, nobody was there to support her. The final thing we know is that, she had one more fall…” Red Cross team member

There was a sense among some professionals that there are now fewer in-home assessments because of financial and capacity issues.

“ Five or ten years ago, this kind of patient we would have probably have done an access visit, where we go out and look at that [their home]. We don't do them as much now because we just don't have the time.” Occupational therapist, Manchester

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A lack of resources

“ [T]hey call it bed nine and three quarters, like Harry Potter. So you’ve got three beds in a row, they’ll squidge them all up and stick another one in between. So, one person won’t even have a curtain, a call bell, oxygen if they need it, and that’s the situation we’re facing at the moment and that’s going to happen this winter again, easily.” A&E nurse, Bradford

Our focus groups with health and social care professionals revealed the ripple effect the pressures on adult social care services are having on the whole system. A lack of capacity in the community is piling pressure on to hospitals, resulting in a lack of available beds and ultimately affecting patient flow in its entirety.

Faced with such pressures they also report being less and less able to provide the person-centred care their patients require.

“ I think it [person-centred care] pays off in the long run from the community worker’s point of view that, even though it does take a bit longer doing it this way, hopefully they won’t bounce back and reuse the service over and over again because you’ve empowered them and taught them how to self-manage.” Community nurse, Bradford

They also spoke about how patients are routinely falling through the gaps that exist between hospital departments, and between hospitals and social care services.

“ It's responsibility tennis, isn't it, a lot of the time. Interdepartmental within the hospital, it's over to you, responsibility, back to you, back – that's what it is, isn't it? People think and work insularly. All they're interested in is their bit, once their bit's done they can sit back in their chair and think okay, I've done my bit. Everything works by link. It's like Lego, everything works by putting things together.” Paramedic, Manchester

The Red Cross volunteers and staff we spoke to are increasingly seeing referrals of people with more complex and higher-level needs. Our own staff and volunteers have told us about increased difficulty signposting people to appropriate support.

“ Our staff and volunteers are not bedside-befriending, tea-and-sympathy any more, it’s really… quite high level stuff these days.” Red Cross team member

Our volunteers and staff are seeing people deteriorate because of restrictive criteria in accessing support. People can receive differential care based not only on where they live but also on their age or condition.

Red Cross staff and volunteers also reflected the lack of services available to people aged between 40-60 years old with lower to moderate levels of needs.

“ Sometimes, those that don't quite fit in, it seems as if they get passed around the houses. By the time they show up at your service, they have already been to three or four others that haven't been appropriate.” Red Cross team member

A greater focus on preventing people reaching crisis pointHealth and care professionals would like to see a greater focus on prevention and believe that the system currently only responds when someone has reached crisis point.

“ We often find so many times that we are literally having to let it get to the worst point in somebody’s life for somebody to actively intervene or do something.” Community nurse, London

Our health and care professionals also mentioned how pressure on social care staff and facilities mean that there is no effective strategy for ensuring existing conditions do not worsen.

14 In and out of hospital

“ In adult social care… the waiting list can be three months and what happens then is you only deal with crises rather than dealing with all the preventative work that would stop that from happening… I think the threshold criteria goes up because, if it's something that can wait, if it's not an emergency, it will just be put to one side until they’ve dealt with all the crises.” Social worker, Bradford

Lack of resources is seen to be a key barrier and, because of budget constraints, people get help only when they reach crisis point. “ Our organisation does nothing [in relation

to prevention], our resources have been scaled back so much. I think we’ve had so many cuts to staff, now it appears to be the sole focus from a Trust perspective is to get people out of the beds.” Physiotherapist, Warmley

Participants from almost all groups spoke positively about falls prevention initiatives, such as hospital-based physiotherapists asking out-patients over 60 to routinely complete a falls questionnaire; routine falls assessments in A&E, exercise classes, proactive falls hazards checks and so on. However, they also noticed falls prevention schemes in the community being cut, most typically due to stretched adult social care budgets.

We believe the involvement of non-clinical personnel in supporting patients and the system is crucial.

How the British Red Cross helps get people home from hospital in 10 simple steps

1. The patient is signposted to our services by hospital staff.

2. We ensure the person has suitable clothes to wear to keep warm.

3. We check they have their medication and know how to and when to take it.

4. We transport a person home, either via assisted public transport or car/ambulance.

5. We ensure a person has their keys and can get into their home OK.

6. We check whether people can move around their homes OK, do they need a mobility aid like a wheelchair, walking frame or commode

7. We check whether the home is habitable, are there trip hazards or any other safety concerns.

8. We check that the power is working and the heating is on.

9. We ensure there are enough supplies, such as whether there is food in the fridge to eat.

10. Next steps – check in with people, connect them with local services, accompany them on shopping trips or appointments and help build confidence and recovery.

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